Deep plane SMAS - how does the SMAS get reattached?

Question

Thankfully all is well after my deep plane smas and eye lift and a few other things. A general set of questions I do not see answered on this amazing forum are of a academic nature. And other may be as interested as I am. That is, when the SMAS is repositioned there is a lot of tension on this SMAS. How mechanically is that held into place? Yes, I know with stitches, but to what? How wide an area is stitched? How careful should one be to avoid detaching the SMAS? Is facial massage ok?

Jeffrey M. Darrow, MD · Answer

You are correct that the main fixation for the SMAS flap is sutures,  which are fixed to the same SMAS at a higher level.  Some surgeons place a lot of sutures that hold the SMAS in an elevated and tightened position and some use two layers of sutures.  The sutures are the initial fixation, but over time the SMAS flap heals and scars into position and that is what holds it in place as the sutures, dissolve and disappear.  This healing is usually complete 4 to 6 weeks and afterwords facial massages should not be a problem.  Best wishes.

J. Timothy Katzen, MD, FACS · Answer

Hi, thank you for your question regarding how the SMAS is reattached in a deep plane facelift. Most plastic surgeons use permanent suture to reattach the SMAS, employing multiple different positions and vectors where the sutures are placed. Usually, the permanent sutures are placed in both a horizontal and vertical plane, although some plastic surgeons advocate for an oblique plane. Typically, the SMAS is attached to itself. Some plastic surgeons remove a layer of the SMAS, and the edges of the SMAS are attached. When the SMAS is reattached to itself, the tissues bunch in the area underneath the attachment. This leads to augmentation in that area, which is beneficial for cheek or malar augmentation. Facial massaging will not disrupt these permanent sutures, as they are strong and durable. However, facial massages should be avoided for at least the first two months to ensure optimal healing. I hope this helps answer your question about how the SMAS is reattached after a deep plane facelift. Good luck.

Sincerely,

J. Timothy Katzen, MD, FASMBS, FICS
Plastic and Aesthetic Surgeon

Sincerely,

J. Timothy Katzen, MD, FASMBS, FICS
Plastic and Aesthetic Surgeon

Lucian Ion, FRCS · Answer

Thank you for your question. It is indeed an aspect that benefits from more detailed explanations in particular when people think about how to best look after themselves in the post operative phase.
The principal, behind the surgery is to release some of the ligaments that stabilise the SMAS and skin to allow better redraping of the facial tissues.
As such, it is often not necessary to use significant tension during the surgery. After the surgery, swelling of the soft tissues, and even limited amount of bleeding increases the volume and therefore creates the impression that there is more tension used by the surgeon to lift and support the SMAS.
The stitches for support of the facelift are anchored to the area of the cheek, which is in front of the ear and is also referred to as the fixed SMAS, as opposed to the mobile SMAS situated further forward. The descriptive name comes from the fact that in that region, the SMAS has strong attachments to the underlying and will not be displaced forward by the suspension sutures.
The area of suspension covers the whole height of the cheek.
Detaching the SMAS is unlikely, but I always advise patients to either have manual lymphatic drainage with a specialist or to do gentle massage, upward, and backward in line with the direction of the lift, and to avoid pushing the facial tissues down.

Stephen Prendiville, MD · Answer

After the composite deep plane facelift flap is elevated and ligamentous structures are released, the entire flap is mobile.  The SMAS flap is then elevated and secured to more superior and lateral fascia using long acting absorbable monofilament sutures (PDS).  Some Surgeons use permanent sutures, but I feel (from experience) that this adds no additional benefit to the procedure and permanent sutures can pose problems with inflammation.

Connie Hiers, MD, FACS · Answer

The SMAS layer is a strong layer of fascia that helps hold things together. The SMAS is cut, a portion is lifted and moved, and then it is reattached to itself with sutures.  Once healed, massage will not damage the fascia.

Terry Maffi, MD · Answer

Yes, the SMAS is elevated, suspended and then stitched to help secure it. Strong sutures are used to suture the SMAS to fascia which is a strong casing of connective tissue that surrounds the muscles of the upper face. 
Detaching the SMAS after surgery is rare however, limiting activity for approximately 3 to 4 weeks after surgery will help prevent this.

William Portuese, MD · Answer

In our practice, the SMAS is lifted off the underlying structures, such as the parotid gland, and is then tightened in a more superior and posterior position with a moderate amount of tension. We use permanent nylon stitches, which are inert. In addition to tightening the SMAS, the goal of a facelift is to tighten, loose facial and neck skin, tighten loose facial and neck muscles, remove fat deposits located both above and below the platysma muscle in your neck, which also includes a platysma plasty to significantly improve the jawline

Deep plane SMAS - how does the SMAS get reattached?

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